Lack of "customer service" as beneficial factor for chronic disease process?

[KatieMI]

I observed the following clinical scenario several times over the last few months and wonder if it is just episodic events or something more.

There is a type of patients who openly abuse acute care system. Such patients have a multitude of chronic conditions which can be managed successfully on outpatient basis, but willfully ignore all recommendations, teachings and the rest of it. Instead, they come to ER within 24 -72 hours after discharge stating symptoms which, as they know perfectly well, would warrant readmission, such as chest pain. Once admitted, they terrorize providers and the rest of staff, refuse interventions which are recommended, demand increase of opioids, benzos and other "good stuff" and, in general, refuse to go home till receiving as much of "customer experience" as possible. The cycle is repeated X times. Then, one beautiful day, karma struck. The patient somehow bent the stick too much and totally and profoundly upset provider and nurses. Therefore, he couldn't get more of his beloved dilaudid 1 mg IVP Q2h, no more phenegran IV, appropriate 2 grams sodium/ADA1500 diet instead of regular, no private room which "they always put me in because that's what I want", and his call lights are somehow always got answered the last. Nurses even stop obligingly wipe his butt upon demand, even though "they always did it for me before". After a couple of temper tantrums, the patient leaves AMA or upon the first opportunity to do so, with a loud promise to (never shop there again) never come back to this bad, bad hospital where "nobody cares for me".

That all is a common and well known and I wouldn't bother with it. But I saw several times recently that the patients in question truly disappeared from the ER for several weeks and, when they finally came back, they were there for legitimate reasons. Moreover, their behavior changed quite a bit. They stopped doing things which caused acute decompensations, such as skipping insulins and breathing treatments. They started to take most of their meds regularly, not only "ma' pain pills". They became more flexible with home and office care. They get flu shots and avoid large gatherings of people during flu season. In other words, they finally started doing what we wanted them to do for years before.

I was so mystified that I asked two of them, indirectly, what happened. The answers were: since I cannot get what I want here, then I do not want to go here anymore unless there is no choice; so, I am just trying to stay out of this hospital. You told me that I have to do (X, Y, Z), so I give it all a try, so I might not have to go where I was treated so badly and couldn't get what I wanted.

These observations prompted me to ask a silly question: can "customer service" paradigm actually attract chronically sick patients with significant knowledge about the system in hospitals and therefore negatively affect their health on the long run? And, as an opposite, can lack of "customer service" prompt these patients to finally take better care of themselves and therefore provide significant benefits for them?

I would be thankful for others' observations and ideas about this topic. "Customer service" is pushed down the throats of all health care providers nowadays, but I never saw any research showing its benefits or lack of them in terms of long-term disease process.

[Ruby Vee, BSN]

I would have to say this customer service is not nonsense when you are being paid by the patient's insurance and from the patient's own pocket.

If the patient doesn't understand that his/her healthcare dollars are paying for HEALTH CARE rather than a luxury accomodation, it IS nonsense.

[trytounderstand]

In watching how my parents treated their healthcare providers with respect, I learned to respect the person in the white coat and of course the nurses, who today, are usually in scrubs rather than the starched white dress I remember. But they in turn were treated with the same respect. When the doctor walked into the hospital room he sat on stool beside the bed and explained everything that was going to be happening for their care rather than standing at foot of bed or bedside with the attitude I am in charge and you do not have a choice in the decision I have made. The nurses treated both my parents with the utmost respect and understood when my father do not want another woman seeing him without at least his underwear on. That he preferred to have my mother perform whatever personal duties needed to be attended to for his care. My mother as well preferred to have one of her daughters to perform her personal care. Both of them felt it was disrespectful to expect a nurse to do any more personal care than was absolutely necessary. In today's nursing and hospital world it is as though all that has been thrown to the winds. In the past few years, it seems as if the patient's dignity does not matter. As a matter of fact it seems that they want to put patients in embarrassing situations and I have even noted that some female nurses seem to enjoy the embarrassing situations for both male and female patients. I have actually heard male nurses and males technicians apologizing while I have not heard that a female nurse in a long time. It is more I have seen it all so its is okay that I see yours and too bad, so sad.

I also know from having surgery and injuries that the best thing to do is listen to the nurses and doctors about getting your mobility back as soon as possible and at times they are going to ask you to do things that cause pain and discomfort but it will make things better in the long run.

I also believe that over the years patients have come to expect that there will be no pain or discomfort and have actually come to rely too heavily on drugs to take care of that pain. This has resulted in doctors being expected to prescribe something that will instantly take the pain away rather than a more safe alternative that may not work as fast or will not give the patient the resulting euphoria so many have come to expect.

My concern with customer service are simple things:

If a patient has said "no" then it is "no"

A patient should not be stripped in front of everyone whether they are caregivers or not....gown removed, blanket removed, underwear cut off, after they have said "no". Especially when there is no medical reasoning behind it all other than the admitting nurse was upset that she had to step up and do someone else's job. Only after she had performed a quick bath did she cover the patient. Uncalled for. If a two trauma teams did not feel this treatment was necessary then I think she should have backed off.

Patients not being properly covered and exposed when visitors walk into a room

Private rooms without bed curtains that provide much needed privacy for bed baths, bed side toilet, urinal or bedpan use, Although they may be private rooms does not mean that someone will not open the door and get full view of patient.

Refusal to listen to the patient when they request second opinion and then getting Physician Assistant to administer a relaxing drug because they are noncompliant

Physician Assistant or doctor not pulling up xrays ct scans mris to show a patient why they feel the course of action is needed.

Assuring a patient that we are all girls or all guys so it is okay if I don't leave the room while you get dressed.

While yes I am sure that it is irritating when a patient refuses a drug or treatment that they do not feel is right for them and again it is their body and their insurance or personal bank account that is paying the bill.

At no time should a family member have to worry that when they have to leave a patient in icu, critical care, operating room, recovery room that their dignity will not be respected. Or that once sedated the patient will not be allowed to lay there exposed to housekeeping, janitors, it people, other visitors, even other healthcare professionals, none of that needs to be on display unless it is truly medically necessary

Nurses not offering tear away shorts or scrub pants so patients do not have to lay in the bed without the lower body covered. Although I realize in some instances it is not prudent to supply the shorts or pants, I have myself have been in that position and left my jeans on because I did not want to have to get up and walk around exposing my backside to other patients, visitors, nurses.

These are the type of customer service items I am talking about. Just normal everyday things that seem to have passed as time passes.

The same goes for patients and family members respecting nurses. A nurse is not a maid that should be at your beck and call. While I appreciate them bringing me a pillow, cot, water, towels as a family member staying with the patient, I would go get it myself if they would show me where to find it rather than have them wait on me. I always try to remember to thank them for every kindness they show. I will try to make a point of talking to the ones who have treated me and the patient with respect and kindness before leaving the hospital if at all possible. The patient also has no right to request personal care that they are capable of performing or insist upon refusing gown or scrub pants when offered exposing the nursing staff to unnecessary body exposure.

I prefer a doctor or nurse who treats me with respect and tells me the truth about my condition and is willing to show me on a screen that this is what has to be done. Then tells me exactly what to expect, not sugar coat it.

[TriciaJ, RN]

Bad Customer Service is also negative for patient's health. When you have patients who will not willing go for medical care because they know their dignity is going to be thrown to the winds by "professional" providers. Because as we know you have seen it all. Or to be offered something to help you relax when there is no reason for a benzodiazepine to be administered other than to make it easier on the nursing staff. Physicians and assistants who refuse to listen to patients questions or apprehensions about their care. Physicians or assistants who no longer actually discuss the options for a patient's care with the patient and expect the patient to just accept what they have memorized from the radiologist report. Physicians and assistants who act like it is imposition for a patient to request to see their actual xray and ct scans and have it visually explained what is going on. Family members who feel they have to worry about how the patient is being treated by staff when they cannot be with them. This is all bad customer service.

I actually always try to treat a medical professional with the same respect that I expect back from them. In real life I even thank the Walmart checker for taking my money because that is the right thing to.

There are bad actors in every profession and no one here is making excuses for them. The "customer service" referred to in this thread addresses a trend in hospitals that requires health care personnel to prioritize the wrong things. The question being posed here is whether patients are now having worse outcomes because the "customer service" model is actually detrimental.

If your loved one was deathly ill and the emphasis seemed to be on providing a spa experience without any patient education or need for the patient to participate in his own well-being, would you consider that quality care?

[LoveMyRNlife]

As a matter of fact it seems that they want to put patients in embarrassing situations and I have even noted that some female nurses seem to enjoy the embarrassing situations for both male and female patients. I have actually heard male nurses and males technicians apologizing while I have not heard that a female nurse in a long time. It is more I have seen it all so its is okay that I see yours and too bad, so sad.

I

My concern with customer service are simple things:

If a patient has said "no" then it is "no"

A patient should not be stripped in front of everyone whether they are caregivers or not....gown removed, blanket removed, underwear cut off, after they have said "no". Especially when there is no medical reasoning behind it all other than the admitting nurse was upset that she had to step up and do someone else's job. Only after she had performed a quick bath did she cover the patient. Uncalled for. If a two trauma teams did not feel this treatment was necessary then I think she should have backed off.

Patients not being properly covered and exposed when visitors walk into a room

Private rooms without bed curtains that provide much needed privacy for bed baths, bed side toilet, urinal or bedpan use, Although they may be private rooms does not mean that someone will not open the door and get full view of patient.

While yes I am sure that it is irritating when a patient refuses a drug or treatment that they do not feel is right for them and again it is their body and their insurance or personal bank account that is paying the bill.

At no time should a family member have to worry that when they have to leave a patient in icu, critical care, operating room, recovery room that their dignity will not be respected. Or that once sedated the patient will not be allowed to lay there exposed to housekeeping, janitors, it people, other visitors, even other healthcare professionals, none of that needs to be on display unless it is truly medically necessary

Nurses not offering tear away shorts or scrub pants so patients do not have to lay in the bed without the lower body covered. Although I realize in some instances it is not prudent to supply the shorts or pants, I have myself have been in that position and left my jeans on because I did not want to have to get up and walk around exposing my backside to other patients, visitors, nurses.

These are the type of customer service items I am talking about. Just normal everyday things that seem to have passed as time passes.

I just wanted to address a few of your statements. Where I work, the male and female RNs and PCAs take great care to respect a patient's privacy and dignity. I am not sure where you had such a negative experience but I would think that is not the norm. A few things you stated are easy fixes. We do not provide scrub pants for patients. If they want their backside covered you simply put another gown on backwards and it is like a robe. Secondly, on my unit we deal with a lot of incontinent patients and we do not want wet underwear or pants up against their skin which would allow skin breakdown. We quite frankly have the opposite problem with some patients where I work. We have people completely capable of wiping their own behind, pulling up their blankets, reaching for a cup, etc that become completely child like when they become an inpatient. Expecting an A & O patient to perform their own ADLs is not a lack of care on the staff but helping the patient to maintain independence if they expect to return back home instead of an ECF.

These are not the issues the OP is addressing.

[trytounderstand]

First of all, I apologize if I have wandered from the gist of this thread.

I am not sure what you consider spa experience. I expect to receive respect when I enter a hospital or doctors office. The same as I expect to show respect in return. I do not expect a nurse to be my maid or my family's maid. But I also do not expect a nurse to refuse to listen when a patient says "no" and to put them in an embarrassing situation or to walk into a room after I have trusted my family member to be treated with respect and see the look of devastation because their dignity was stripped from them for no medical reason. I do not expect a nurse or technician to refuse to leave the room while I am getting dressed because we are all girls or guys here so what does it matter. Actually had that said to me. I do not expect a spa experience I expect respect from all parties myself included.

I know that sometimes patients will make a choice that may go against what the nurse or doctor think is in their best interest. But once they have listened to your advice and decided they want to go a different route it is their body, their choice. I expect to be able to make an informed choice and to be part of the "team" who is deciding my care. Again my body, my choice. Unless it is an emergency situation every patient should decide whether they are taking blood thinners, stool softeners, pain meds, benzos (by the way all effects of those drugs should be explained before administered as well), wishes for a second opinion should be respected. Actual xrays mri ct scans should be presented to the patient and all physician assistants, nurse practioners and doctors should be able to explain to the patient exactly what they are looking at and why they are suggesting the course of treatment. If the patient goes against what the team without his/her input decided, they should not be considered noncompliant/uncooperative. They and they alone know what some medications will do to them once it enters their body and if they do not want to take it someone should listen. It is still their body, their choice. Should just be recorded as patient refused treatment or medicine and move on and not affect how the patient is treated for the rest of the shift.

I do believe that some patients think they should be waited on hand and foot and that is wrong. I also believe that in trying to prevent patients from experiencing pain the pendulum has swung too far as not considering alternative methods to opiates or benzodiazepines to control pain and anxiety. I can remember years ago being in a hospital for surgery as the night wore on and I could not sleep the nurse who was checking on me said you should be asleep and I have given everything the doctor ordered. Then he said let me get the floor nurse. She came in and we talked she then took me for a walk up and down the hall. Yes it hurt. Yes I had to have help from two nurses to make sure I could make that first trip up and back to my room. But after that the pain subsided and I was able to sleep. Forever I will be grateful to that nurse for realizing I did not need more sedation I just needed a simple walk for my body to relax and take over and let me sleep.

[LoveMyRNlife]

First of all, I apologize if I have wandered from the gist of this thread.

I am not sure what you consider spa experience. I expect to receive respect when I enter a hospital or doctors office. The same as I expect to show respect in return. I do not expect a nurse to be my maid or my family's maid. But I also do not expect a nurse to refuse to listen when a patient says "no" and to put them in an embarrassing situation or to walk into a room after I have trusted my family member to be treated with respect and see the look of devastation because their dignity was stripped from them for no medical reason. I do not expect a nurse or technician to refuse to leave the room while I am getting dressed because we are all girls or guys here so what does it matter. Actually had that said to me. I do not expect a spa experience I expect respect from all parties myself included.

I know that sometimes patients will make a choice that may go against what the nurse or doctor think is in their best interest. But once they have listened to your advice and decided they want to go a different route it is their body, their choice. I expect to be able to make an informed choice and to be part of the "team" who is deciding my care. Again my body, my choice. Unless it is an emergency situation every patient should decide whether they are taking blood thinners, stool softeners, pain meds, benzos (by the way all effects of those drugs should be explained before administered as well), wishes for a second opinion should be respected. Actual xrays mri ct scans should be presented to the patient and all physician assistants, nurse practioners and doctors should be able to explain to the patient exactly what they are looking at and why they are suggesting the course of treatment. If the patient goes against what the team without his/her input decided, they should not be considered noncompliant/uncooperative. They and they alone know what some medications will do to them once it enters their body and if they do not want to take it someone should listen. It is still their body, their choice. Should just be recorded as patient refused treatment or medicine and move on and not affect how the patient is treated for the rest of the shift.

I do believe that some patients think they should be waited on hand and foot and that is wrong. I also believe that in trying to prevent patients from experiencing pain the pendulum has swung too far as not considering alternative methods to opiates or benzodiazepines to control pain and anxiety. I can remember years ago being in a hospital for surgery as the night wore on and I could not sleep the nurse who was checking on me said you should be asleep and I have given everything the doctor ordered. Then he said let me get the floor nurse. She came in and we talked she then took me for a walk up and down the hall. Yes it hurt. Yes I had to have help from two nurses to make sure I could make that first trip up and back to my room. But after that the pain subsided and I was able to sleep. Forever I will be grateful to that nurse for realizing I did not need more sedation I just needed a simple walk for my body to relax and take over and let me sleep.

I would recommend that you re-read the thread. Not one response that I read expects the patient to follow exactly what is recommended by the physician. We all recognize that people have choices. The problem with some people is that they do not recognize the consequences of their choices and want to blame the entire healthcare team. We are not in the business of forcing people to take care of themselves, we can only educate.

It is not disrespectful of the RN or MD to tell the pt with COPD,CHF,DM, and CKD, on their 5th admission in a year, that they may want to start following the diet recommended and stop smoking. The pt has every right not to follow the recommendations but then do not complain endlessly that you feel like crap because it is the MDs fault for not "fixing you".

Again, this is not the OPs question/thought so I will not hijack the thread anymore. Sorry you or your family member had such a negative experience. I work with excellent people that love what we do most days and would never treat people in the manner you have described.

[trytounderstand]

Again I apologize for getting off the subject. I more than appreciate when a healthcare provider gives me the information that I need and allows me to take this information and help make an informed decision on my healthcare. But in this case it was more like we are the "team" and we have made the decision. It was truly one of the longest days of my life watching what was happening and feeling that I could not stop it or being afraid to overstep because I did not know how that patient would be treated after I had to leave the area.

[KatieMI, BSN, MSN, RN]

Trytounderstand,

First of all, I am very sorry for what you went through.

Second, my question is not about respect or lack of it. It is about facts of life which some people willfully choose to ignore despite of being repeatedly informed about them, and similarly willful actions, mostly by health care administration, letting these people to go away with it in the name of "customer satisfaction".

If a patient with known and proven beyond reasonable doubts CHF chooses not to follow salt-free diet, it is his business as long as he is informed about what happens as a result (no improvement in his condition doesn't matter how many miracle pills he is taking and eventually death). Now, if that patient is in health care facility, has an acute CHF exacerbation directly related his refusal to follow salt-free diet, has direct provider order for that diet and still demands salt, would it be ethical to allow him to, essentially, aid to his disease in the name of keeping him "satisfied"? Or, even more, try to influence provider into dropping the diet order and not providing salt-free food at all under the same premice (recently witnessed practice in LTC)?

You see, as things stay right now, US economy will not sustain health care spendings if they continue to grow as they are. That's just economics reality, plain and simple. It is muiltifactorial, but managing sequelae of chronic health care condition constitutes a huge part of it. Smoking alone adds $160 billion every year (if we leave alone extrapolated number of $300 billion):

How Much Can the USA Reduce Health Care Costs by Reducing Smoking?

Obesity adds 21% to total:

The Epidemiology of Obesity: A Big Picture

Considering all this, should we as health care workers provide patients with conditions and information which, essentially, encourage their bad healthcare choices just because they like it more this way? Because that's what we do when we allow morbidly obese CHF patient to enjoy his salty cheeseburger for lunch because "he's a customer and wants to have it", instead of facing the heat and fury and letting him make just yet one more bad decision by signing out AMA.

As I said, I see patients banned from "customer service experience" making at least some efforts to improve themselves because they do not want to go back where they were treated "badly and without respect" (if we count refusal of inappropriate diet and treatments as "disrespect"). Ridiculously, but only one such "negative customer experience" seems to prevent, statistically, at least one readmission for every patient who starts to make conscious efforts to stay away from hospital, accounting for the fact that the absolute majority of the subjects are dedicated "frequent fliers" with regular and predictable admission patterns. And I see patients treated with all bells and whistles entering the death circle of "ER >>ICU >> floor >> rehab >>ER" because either party caters to their whims and wants instead of legitimate and evidence- based medical interventions.

[LadysSolo]

"If a patient with known and proven beyond reasonable doubts CHF chooses not to follow salt-free diet, it is his business as long as he is informed about what happens as a result (no improvement in his condition doesn't matter how many miracle pills he is taking and eventually death). Now, if that patient is in health care facility, has an acute CHF exacerbation directly related his refusal to follow salt-free diet, has direct provider order for that diet and still demands salt, would it be ethical to allow him to, essentially, aid to his disease in the name of keeping him "satisfied"? Or, even more, try to influence provider into dropping the diet order and not providing salt-free food at all under the same premice (recently witnessed practice in LTC)?"

I have witnessed in LTC because of state regulations, if diabetics want pancakes with ice cream topping for breakfast, lunch, and dinner, the facilities have to attempt to accommodate these requests because the LTC facility is their home, and if they were living in the community and that was what they wanted they could have it. In theory I agree, but often these people are not cognitively capable of making appropriate decisions, hence the LTC facility. So why are they allowed to make inappropriate meal choices? If their guardian signs off on it, okay, but otherwise, I don't think unwise decisions are appropriate. If they wanted to go outside in only their underwear in 20-degree below zero weather, should we allow it? If they wanted to drink bleach, should we allow it? It is their right, because they want to do it, correct? Competent adults are allowed to make bad decisions, but not all adults are competent (even some who have not been declared incompetent.)

[TriciaJ, RN]

Again I apologize for getting off the subject. I more than appreciate when a healthcare provider gives me the information that I need and allows me to take this information and help make an informed decision on my healthcare. But in this case it was more like we are the "team" and we have made the decision. It was truly one of the longest days of my life watching what was happening and feeling that I could not stop it or being afraid to overstep because I did not know how that patient would be treated after I had to leave the area.

Sounds like you have an issue with a previous hospitalization. It really doesn't fit with this thread. If not too much time has elapsed, you might want to contact the patient advocate at the hospital in question and air your concerns.

[lilmiz, ASN, RN, EMT-P]

I really love this discussion, and I am going to have to agree this whole customer service in healthcare is ridiculous. First of all it couldn't be more obvious that our hospitals are being ran by business people who have no idea what good medical management is. Their decisions are based solely on the bottom line, and legally covering their assets. So naturally they want their "customers" to be pleased. Unfortunately we are not a restaurant or retailer we are healthcare providers and many times that means telling a patient things they don't want to hear or advising them about lifestyle changes that they need to make. We have to tell cardiac patients that they need to lose weight, modify their diet, quit drinking etc. Diabetics that they need to check their sugars and McDonald's can't be a regular thing. We are constantly short staffed, given more and more "checklists" to check our checklists. Told we have a new protocol for all patients. I work in the ICU and I would say 80% of the time at least 2-3 of our beds are homeless ETOH withdrawals or IV drug users with complications. Also a big source of admissions lately has been DKA, and GIB homeless of course. Then we have our frequent fliers who have abdominal pain, anxiety, ptsd, fibromyalgia, and chronic pain. Then there is the actual sick, critical patients. I would say 90% of the homeless patients are entitled, rude, verbally abusive and many times physically abusive. As well as non compliant and exhausting. The drug addicted know that they can come and get their drugs as well as act like we run a hotel/ bed and breakfast. I wish we could just do our jobs and care for patients and not have to worry about press ganey, or hcaps, or DNV surveys in order to get a mineute reimbursement from Medicare/Medicaid. I also hate having to fight for my patients to be transferred to other facilities for appropriate care that we can't provide, and administration is dragging their feet, and asking why the patient can't be managed with us. It's become the twilight zone as far as administration hindering proper medical treatment and guidelines. And one last complaint, as far as nursing direct supervisors and "clinical educators" I have noticed a disturbing trend. Our Supervisers have had less and less direct patient care and floor experience. The clinical educator for Med/Surg and ICU has had only 2years of med/Surg experience as a floor nurse and is supposed to be educating the ICU staff?? Oh and all the charge nurses from the last five years are brand new less than 3yrs experience as a floor nurse and no other hospital experience. It causes the floor to be unorganized and the staff nurses to be overwhelmed and have to seek out help from other departments when problems arise. But they make Admin happy by doing whatever they want and slamming the floor with admissions like a factory. Great customer service opportunities, order for admission bring them on up who cares if the rooms ready, or the nurse is ready, or if the level of care is appropriate.